Social phobia

The term "phobia" means an irrational fear of certain objects, circumstances or situations. Phobias are classified by the nature of objects or situations that cause fear. DSM-IV identifies three types of phobias: agoraphobia , closely related to panic disorder, specific phobias and social phobia , or social phobia.

[1], [2], [3], [4], [5], [6], [7]

Pathogenesis

Compared with panic disorder, the pathogenesis of social phobia is much less studied. The bulk of research is devoted to the search for biological markers of panic disorder in patients with social phobia. These studies have revealed a close relationship between panic disorder and social phobia, both in individual patients and at their family level.

[8], [9], [10], [11], [12], [13], [14], [15], [16]

Biological markers of panic disorder

For a number of biological indicators, patients with social phobia occupy an intermediate position between patients with panic disorder and mentally healthy persons. Thus, in patients with social phobia, a more intense anxiety reaction was observed in response to inhalation of carbon dioxide than in healthy individuals, but less intense than in patients with panic disorder. In patients with social phobia, there was also a smoothing of the growth hormone secretion curve with the administration of clonidine, however, because of this phenomenon they also occupy an intermediate position between healthy individuals and patients with panic disorder. Although vegetative theories predict an increase in cardiac reactivity in response to social stimuli, the results of preliminary studies suggest the opposite - in patients with social phobia, a decrease in cardiac reactivity was revealed when exposed to social stimuli. The results of neuroendocrine tests indicate the dysfunction of the serotonergic system in social phobia; however, further studies are needed to compare these indicators in healthy individuals, patients with panic disorder, social phobia and major depression.

[17], [18], [19], [20], [21], [22], [23], [24], [25], [26]

Specific changes in social phobia

Genealogical and long prospective studies indicate a kind of transmission of social phobia, which can be attributed to the uniqueness of the disease itself. Indeed, social phobia has the earliest debut of all anxiety disorders, in most cases manifested in adolescence.

Temperament in childhood and social phobia

There are credible data on the relationship between anxiety disorders and restrained behavior in an unfamiliar situation. In a new situation, especially in the presence of others, children with a special type of temperament subsided. These children do not dare to talk to a stranger for a long time, do not take part in group games, their facial expressions are shackled - all this resembles manifestations of social phobia. Studies show that restrained behavior has strong genetic roots, although it is also subject to the influence of external factors. It is assumed that restrained behavior is the result of an anomalously low threshold of excitation of the amygdala, but there are only indirect proofs of this assumption. Apparently, the connection between restrained behavior and social phobia is not so unambiguous. There is evidence that restrained behavior is more closely associated with panic disorder than with social phobia. Nevertheless, data on the relationship between low-tempered behavior in early childhood and adolescent social phobia continue to accumulate.

Functional asymmetry of the brain

It is assumed that the asymmetry of the functions of the frontal lobes is related to the behavioral features. With the predominance of the frontal lobe of the right hemisphere, a person chooses a passive behavior strategy more often in a stressful situation (including in a social situation), whereas with an increased activity of the left frontal lobe, a person chooses an active coping strategy. In children with restrained behavior, the right frontal lobe predominates, which predetermines the choice of a passive strategy. The main limitation of this theory is its lack of specificity - it is applicable not only to social phobia, but rather explains predisposition to a wide range of anxiety and affective disorders.

Stages

Social phobia usually occurs during adolescence and adolescence. The generalized form tends to be chronic, although, as with other anxiety disorders, there is not enough evidence in this regard for prospective epidemiological studies. Both retrospective epidemiological and prospective clinical studies show that social phobia can over the years exert an extremely unfavorable influence on various spheres of the patient's life: study, work, social development.

[27], [28]

Diagnostics of the social phobia

• Expressed or persistent fear of being in one or more social situations characterized by the presence of strangers or possible attraction of the attention of others. The patient fears that he will find his fear or act in such a way that he finds himself in an awkward or humiliating situation. Note: children should have an appropriate development of social relationships with familiar people, and anxiety should arise when communicating not only with adults, but also with peers.
• When you get into a frightening social situation, he almost always has an anxiety that can take the form of a situationally or conditionally situationally predisposed panic attack. Note: in children when dealing with strangers, anxiety can be expressed in crying, outbursts of irritation, fading or stiffness.
• The patient understands that his fears are excessive and irrational. Note: this sign does not exist in children.
• The patient tries to avoid situations of communication or public speaking that cause his fear, or tries to overcome intense anxiety and discomfort.
• Avoidance, anxious anticipation or discomfort in intimidating situations of communication or speech significantly hamper his daily activities, work, study, social activity, relationships with other people, or the very fact of having a phobia is a cause for concern.
• In persons under 18 years of age, symptoms should persist for at least 6 months.
• Fear and avoidance are not caused by the direct physiological action of exogenous substances (including addictive drugs or medicines) or a common disease and can not be better explained by the presence of another mental disorder (panic disorder with or without agoraphobia, separation anxiety disorder, dysmorphophobia , general developmental disorder or schizoid personality disorder).
• In the presence of a common disease or other mental disorder, the fear qualified by criterion A is not relevant to them (for example, fear is not caused by stuttering, tremor in Parkinson's disease or fears of finding pathological eating habits in anorexia nervosa or bulimna).

If fear arises in most social situations, then a generalized type of social phobia is diagnosed (social phobia can be accompanied by a phobic personality disorder)

Diagnosis of social phobia requires the presence of intense anxiety, which can take the form of a situational panic attack in a situation where the patient is forced to engage in communication, publicly perform certain actions and may be in the spotlight or embarrassing situation. Fear can arise only in special situations (for example, if necessary, write, eat or speak in the presence of others) or have a more vague general character in the form of fears of confusion with someone. In DSM-IV, there is a special generalized type of social phobia, in which the patient is afraid of most social situations. Such people are afraid to enter into communication in a variety of situations, participate in public events, they are afraid to come into contact with representatives of the authorities. Diagnosis of social phobia requires that fear or hamper the life of the patient, or cause severe discomfort; it is also necessary for the patient to recognize the excessiveness and irrationality of his fears and either avoid social situations or with difficulty overcome his discomfort.

Many people, while in society, experience some degree of anxiety or embarrassment, which, however, do not meet the criteria of social phobia. The results of sociological research show that more than a third of the population believes that in social situations they are experiencing more significant anxiety than other people. However, such anxiety is a sign of social phobia only if it interferes with the realization of the conceived actions or causes severe discomfort in their implementation. In individuals with more specific forms of social phobia, fear is associated only with certain social situations. For example, fear of public speaking can be so pronounced that it will make it difficult to fulfill professional duties - this is one of the most frequent variants of a specific social phobia.

Like all anxiety disorders, social phobia is often combined with other anxiety and affective disorders. The most attention is drawn to the connection of social phobia with panic disorder and major depression. There is also a link between social phobia and drug addiction and obedience disorder in children.

[29], [30], [31], [32], [33]

Differential diagnosis

Patients may find symptoms of social phobia in various circumstances. One of the most characteristic scenarios is that the patient does not cope with the job or can not adapt to the social environment, as he is unable to fulfill certain tasks or tasks. Another scenario, less characteristic of social phobia, is that the patient has an acute need to have friends or family, but can not overcome social isolation.

Since social isolation can be caused by various mental illnesses, the diagnosis of social phobia in such cases is quite difficult. Special difficulties are caused by differential diagnosis of social phobia and agoraphobia, because both disorders are associated with fear of situations of congestion. The key difference is the direction of fear. Patients with social phobia are afraid to come into contact with people, patients with agoraphobia are afraid not to communicate with people, but are afraid to find themselves in a situation from which it is difficult to get out. Moreover, in some situations, patients with agoraphobia feel calmer in the presence of other people, if those, due to the peculiarities of the place of stay, are unable to prevent them from getting out. While with social phobia, patients avoid any communication.

Difficulties also arise in the differential diagnosis of social phobia with social isolation caused by major depression or early manifestations of psychosis. In this case, two things should be kept in mind. First, social isolation in social phobia is caused by anxiety and fear associated with social situations, while patients with depression or developing psychosis are locked in themselves for other reasons. Secondly, with social phobia, the symptomatology is limited to fear associated with social situations, while in other disorders social isolation is accompanied by other psychopathological manifestations that are not characteristic of social phobia.

Unlike panic disorder, social phobia rarely requires differential diagnosis with somatogenic anxiety disorders. Secondary anxiety disorders usually arise against the background of severe somatic symptoms and are not associated with certain social situations. Nevertheless, as with the diagnosis of panic disorder, patients with manifestations of social phobia need a detailed history and a thorough physical examination.

[34], [35], [36], [37], [38], [39], [40], [41], [42]